PART II - MUST BE COMPLETED BY BORROWER
4. Employment Information:
Provide information for current or most recent employer.
City State Zip
Employer Phone: ( )____________________________
Number of Hours Worked per Week:
Hourly Rate: Date last worked:
Check all that apply:
I am employed and experiencing financial difficulty
(See financial statement on previous page)
I am seeking and unable to secure full-time employment.
I have registered with an employment agency.
(Provide registration documentation)
I am receiving unemployment benefits.
(Provide official documentation of this benefit)
I am not eligible to receive unemployment benefits.
(Provide supporting documentation of ineligibility)
I have never been employed.
5. Other situations. Check all that apply: (Supporting documentation may include: check stubs, employer stubs, benefit
verification on official letterhead, copy of Federal Tax Return)
I have been granted economic hardship for a Federal Direct Student Loan or a Federal Family Education Loan. (Indicate
dates of hardship period:
Attach official documentation of this benefit.
I am receiving payment under federal or state public assistance. (AFDC, SSI, Food Stamps, State-sponsored General
Attach supporting documentation.
6. Describe below the circumstances of your present financial situation.
7. If you feel you can make payments toward your account(s), complete this section.
Based on my financial situation, I can make monthly payments in the amount of $
. If this agreement is
approved, I will make payment of this amount each month as a condition of this agreement. If payment is not made, I
understand that this agreement may be terminated by the lending institution.
If payment is not received between the first and the fifteenth of each month, you will receive past due notices which reflect all
past due amounts based on your original repayment schedule.
I am able to pay the interest due
any hardship or forbearance benefit granted, please bill me.
I am unable to pay the interest due throughout any hardships or forbearance benefit granted. I will pay the interest
my hardship deferment or forbearance has ended. I understand interest that has accrued will be billed in a
lump sum at the end of the hardship deferment or forbearance and is due and payable upon receipt.